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The EpiNotes Newsletter | Page
Summer 2015
Cover: Estuarine shoreline (Courtesy of DENR)
PAGE
Vibriosis in North Carolina: 1997—2014 2
Clinical Impact of the June 2015 Heatwave 5
Concerns and Cost of Monkey Bites 6
Vapor Intrusion and Residential Health 9
News and Events 10
Employee of the Quarter 11
Contact Us 12
The
EpiNotes
Newsletter
North Carolina Department of
Health and Human Services
The EpiNotes Newsletter | Page 2
V ibrio infections are the leading cause of
deaths linked to under-cooked seafood
in the United States. There are more
than 200 recognized species of Vibrios,
however, in the United States, only a few are
known to cause disease in humans, vulnificus,
parahaemolyticus and alginolyticus
being the major ones.
Infections are often
acquired from
exposure to sea water
or eating raw oysters
because the bacteria
lodges in the tissues of
mollusks such as oysters,
clams, mussels and crabs.
Typically, the incubation
period is 4 to 92 hours. In the
United States, vibrio infections
are nationally notifiable and
account for an estimated 80,000 illnesses, 500
hospitalizations and 100 deaths each year1,2.
In North Carolina, disease reports are categorized
into Vibrio vulnificus infection and vibrio other
infection (other than vulnificus and toxigenic
cholerae). Vibrio species can cause a variety of
clinical syndromes, including gastroenteritis,
wound infection, fever and septicemia. By
decreasing order of occurrence, the three distinct
syndromes of V. vulnificus infections are wound
infection, septicemia and GI tract infections3,
whereas, the three distinct syndromes of V.
parahaemolyticus infections are GI tract infections,
wound infection and septicemia4. Wound infection
is severe in people with liver disease or
immunodeficiency. V. vulnificus
infections often occurs following
wound exposure to contaminated
water and most V.
parahaemolyticus cases report
consumption of raw or
undercooked seafood.
The clinical case definition
used for surveillance
purposes is an infection of
variable severity
characterized by diarrhea
and vomiting, primary
septicemia, or wound infections. A
confirmed case meets the clinical case definition
with isolation of pathogen from a clinical
specimen; a probable case is a clinically-compatible
case that is linked to a confirmed case but does not
meet the laboratory criteria for diagnosis.
We extracted vibriosis case data for 1997 to 2014
from NC EDSS (North Carolina Electronic Disease
Surveillance System) to obtain demographic,
clinical and epidemiologic information. The NC
EDSS investigation form includes data on
demographics (age, sex, race, county of residence),
clinical information (symptoms, duration of illness,
pre-existing medical conditions such as liver
disease, diabetes and other underlying conditions,
whether the patient was hospitalized and health
outcomes) and epidemiologic information (recent
travel information, seafood exposure and contact
with water). Data were analyzed using SPSS 19. Chi
-square tests were used to compare the health
outcomes and risk factor proportions among V.
vulnificus and other V. spp.
A case was defined as foodborne if the patient
reported seafood consumption/ handling as the
only exposure and as waterborne if the patient
reported water exposure (with or without pre-existing
or sustained wound(s)) as the only
exposure.
Over a span of 18 years (1997 – 2014), a total of
334 cases of vibriosis were reported to local health
departments. Of these, 72% were male, 52% were
over 50 years of age, and 81% were white, non-
Hispanic. Most cases (54%) were residents of the
Coastal region of the state, followed by Mountain
(37%), and Piedmont (10%). The most frequent
species identified by culture were V.
parahaemolyticus, (29%), V. vulnificus (26%), V.
alginolyticus (18%) and V. fluvialis (9%) followed by
other less common species. Fever, nausea and
cellulitis were more likely with vulnificus infections
and fever, nausea, diarrhea, abdominal cramps
were more characteristic of parahaemolyticus
infections. Diarrhea was significantly more
common among cases with parahaemolyticus
(47%) infections when compared with vulnificus
cases (24%; p<0.05). (Table 1).
The Epidemiology of Vibriosis Infections
in North Carolina: 1997—2014
Mounika Bazar; Aaron Fleischauer, PhD; Chris Pierson; Nirmalla Barros, PhD; and Carl Williams, DVM.
Photo (CDC)
The EpiNotes Newsletter | Page 3
Pre-existing liver disease and immune-suppressing
conditions were significantly more common among
persons with V. vulnificus infections (22% versus
3%; 44% versus 18%; respectively p<0.05)
compared with person with V. parahaemolyticus
infections. No difference was observed in persons
with diabetes. Hospitalization was also more
common among cases with V. vulnificus (56%)
infections compared with V. parahaemolyticus
(45%) and other species. Among the 19 deaths, 18
occurred in patients with V. vulnificus infections
(case fatality rate of 21%) and one in patient with
V. parahaemolyticus infection (case fatality rate of
1%). Hospitalizations and case-fatality rates were
observed to be lower than the national rates.
Other risk factors were mostly similar when
comparing V. vulnificus with V. parahaemolyticus
and consistent with national data: 54% of cases
were foodborne and 37% were non-foodborne
(unknown in 9%). Water exposure with pre-existing
or sustained wound(s) difered significantly
though, with 30% in vulnificus infections versus
20% among persons with parahaemolyticus
infections, p< 0.05. No significant diference was
found when considering water exposure alone (7%
in both), wound infection (7% versus 4.2%), shell
fish consumption/ handling (45% versus 52%),
finfish consumption/ handling (5% versus 2%).
(Table 2).
Vibriosis is seasonal. Incidence peaks annually in
June, July and August; twice as many cases occur in
summer than non-summer months and a second
peak was observed in November (Figure 1). There
appears to be a very modest increasing trend over
the study period. In 2012 however, a marked
increase in incidence was observed for reasons
unknown. (Figure 2).
Discussion:
While reported vibriosis infections are relatively
rare in North Carolina, the illness can be serious
and is often preventable. In North Carolina as
elsewhere, V. vulnificus has a higher case fatality
rate than other vibrio species; however the case
fatality rate observed in North Carolina was lower
than that reported in national averages (20% v.
32%). Among reported cases, older white males
tend to be more at risk for infection, possibly as a
result of higher risk associated with occupation or
dietary choices. Pre-existence of co-morbid
conditions likely increases the risk of severe
vibriosis infection, particularly diabetes, liver
disease or other immune-suppressing conditions
(N. A. Daniels, 2011). Co-morbid liver disease and
immune suppressing conditions increase the risk of
hospitalization and death. V. vulnificus infections
are known to be more severe than other species,
but nearly 43% of all reported vibriosis cases were
hospitalized.
The seasonality of vibriosis suggests that marine
and estuary water temperatures are an important
factor in the epidemiology of the disease. It is also
associated with a behavioral-dependent exposure;
an increased number of people take their coastal
vacation in the summer months. Clinical
information for cases before 2008 was not
available for this study, as web-based surveillance
was not introduced until 2008. Data completeness
has significantly improved after the
implementation of NC EDSS, enhancing our ability
to characterize reportable diseases. However our
surveillance has some limitations. For example,
many potential cases do not receive diagnostic
testing which leads to under-reporting particularly
for those Vibrio species that cause milder illness.
Demographics N=334 %
Age:
0-10
11-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
29
24
24
35
49
52
57
46
18
8.7
7.2
7.2
10.5
14.7
15.6
17.1
13.7
5.3
Gender:
Male
Female
Unknown
240
91
3
71.8
27.3
0.9
Race/Ethnicity:
White (NH)
Hispanic
African American
Asian
American Indian
Unknown/other
269
5
29
8
5
18
80.6
1.5
8.7
2.4
1.4
5.4
County of Residence:
Coastal
Piedmont
Mountain
179
33
122
53.6
9.9
36.5
Vibrio subtype:
parahaemolyticus
vulnificus
alginolyticus
fluvialis
hollisae
mimicus
damsela
cholerae
cholera non O1
harveyi
unknown
96
86
61
26
13
8
5
5
14
2
18
28.7
25.8
18.3
7.8
3.9
2.4
1.5
1.5
4.2
0.5
5.4
Hospitalized? (Yes) 143 42.8
Died? (Yes)
19
5.7
Table 1. Demographics among persons with vibriosis.
The EpiNotes Newsletter | Page 4
Recommendations: Infections caused by Vibrio
species can be prevented by thoroughly cooking
sea food, especially oysters and clams. Persons
who are immunocompromised, especially those
with liver disease or HIV, should avoid eating raw
or undercooked shell fish.
Wound infections can be prevented by appropriate
wound care and avoiding exposure of open
wounds to sea water and marine environments.
Fishermen and persons handling shell fish should
wear protective gloves to decrease the risk of
puncture wounds.
Restaurants should always provide food advisories
to their customers about undercooked or raw sea
food. People should be educated about vibriosis
symptoms and be encouraged to inform their
health care provider if they become ill following
estuarine and/or shellfish exposure.
References:
1. Centers for Disease Control and Prevention.
Retrieved June 15, 2015, from htp://www.cdc.gov/
vibrio/index.html
2. Centers for Disease Control and Prevention.
National Enteric Disease Surveillance: COVIS annual
summary, 2012. Retrieved June 15, 2015, from
htp://www.cdc.gov/ncezid/dfwed/pdfs/covis-annual-
report-2012-508c.pdf
3. Daniels, NA. Vibrio vulnificus oysters: pearls and
perils. Clin Infect Dis. 2011. 15; 52(6): 788–792.
4. N. A. Daniels, L. MacKinnon, R. Bishop, S.
Altekruse, B. Ray, R. M. Hammond, S. Thompson, S.
Wilson, N. H. Bean, P. M. Grifin, et al. Vibrio
parahaemolyticus infections in the United States,
1973-1998. J Infect Dis. 2000. 181(5): 1661–1666.
Risk Factor V. vulnifi-cus
(N=86)
V. parahaemolyti-cus
(N= 96)
V. spp. Other
(N=134)
Compar-ison
Water exposure
6 (7%)
7 (7.3%) 24 (18%) NS
Water exposure with
pre-existing wound
26 (30.2%) 19 (19.8%) 23 (17%) p<0.05
Presence of wound (no exposure
to risk factors)
6 (7%) 4 (4.2%) 8 (6%) NS
Shell fish consumption/handling 39 (45.4%) 50 (52.1%) 46 (34%) NS
Fin fish consumption/handling 4 (4.7%) 2 (2.1%) 3 (2%) NS
Diabetes 15 (17.4%) 13 (13.5%) 14 (11%) NS
Liver disease 19 (22.1%) 3 (3.1%) 1 (0.8%) p<0.05
Immuno-suppressed 38 (44.2%) 17 (17.8%) 36 (27%) p<0.05
Table 2. Epidemiologic Risk Factors and Vibriosis by Species
Figure 2. Vibriosis cases reported by year of diagnosis,
North Carolina, 1997 – 2014.
Figure 1. Seasonal distribution of Vibriosis cases by month
of diagnosis, North Carolina, 1997 – 2014.
The EpiNotes Newsletter | Page 5
June 2015 Heatwave
Makes Big Impact
Lauren Thie, MSPH & Sara Smith, MA
Heatwaves are common in North Carolina most
summers. During June 15-24, 2015 there were 10
consecutive days of heat advisories
(heat index of 105°F or greater)
issued by the U.S. National Weath-er
Service ofices serving North Car-olina.
Over the 10 day heat wave,
917 emergency department (ED)
visits for potential heat-related ill-ness
were observed. The majority
of ED visits occurred in the Pied-mont
and Coastal regions. This
number of ED visits far exceeded
what is expected during a typical
summer period, and was much
greater than the same period over
the previous two summers. A dash-board
was developed in response
to highlight the clinical impact the
heatwave had on North Carolinians
(Figure 1).
Prevention: Heat-related illness can
be prevented if proper precautions are fol-lowed.
Some evidence-based messages include1:
 Increase fluid intake
 Reduce activity during the hotest part of the
day (typically 11 am – 4pm)
 Spend some time in air-conditioning
 Consult your physician if you take medications
that reduce the body’s ability to cool itself
(e.g., blood pressure medications, psychologi-cal
medications).
Acclimatization plays an important role in health
and played a major role in this year’s heatwave. It
takes the body about 7-14 days to acclimate to
high temperatures. Since this year’s heatwave
came in early June, prior to any periods of high
temperatures, it was especially dangerous. Accli-matization
also plays an important role in health
protection for those in outdoor professions. Those
new to the job or recently returning from leave will
need to acclimate to the heat before working the
same amounts as those who have been working
outside continually this summer2.
Research indicates the combination of poor air
quality and heat exposure creates particularly dan-gerous
health impacts, more so than either threat
individually. Typically, days with poor air quality
are days with high heat. In response, heat illness
messaging now includes information on poor air
quality. In collaboration with the North Carolina
Department of Environment and Natural Re-sources,
Division of Air Quality, a flyer was devel-oped
to outline ways older adults can protect their
health from air pollution and
heat. Approximately 2,000 flyers
have been distributed to older citi-zens
(over the age of 65) and those
adults living with disabilities by the
Department of Health and Human
Services, Division of Aging & Adult
Services in conjunction with Opera-tion
Fan Heat Relief.
Each year from May through Sep-tember,
weekly heat-related illness
reports are distributed to our key
stakeholders and posted on the
OEEB website. To join this listserv,
please contact Lauren Thie at lau-ren.
thie@dhhs.nc.gov.
For more information on preventing
heat-related health issues, please
visit: htp://publichealth.nc.gov/
chronicdiseaseandinjury/heat.htm
References
1. Hajat, S., O’Connor, M., & Kosatsky, T. (2010).
Health efects of hot weather: from awareness of
risk factors to efective health protection. The Lan-cet,
375, 857-863.
2. Arbury, S., Jacklitsch, B., Farquah, O., Hodgson, M.,
Lamson, G., Martin, H., & Profit, A. (2014). Heat
illness and death among workers – United States,
2012-2013. MMWR, 63(31), 661-5.
Heat Related Illness Dashboard
June 15 – 22, 2015
Total Emergency Department
visits for heat-related illness
917
Percent of Emergency
Department visits Hospitalized
10%
Averagemaximum heat index
during this timeframe (RDU
Airport)
103F
Recommendations
• Drink fluids
• Spend some time in air conditioning
• Reduce activity between 11 am – 4 pm
• Consult your doctor if you take medications
that impact the body’s ability to lose heat
Proportion of ED Visits attributed to Heat Related Illness
2015 compared with previous 2 years
Data Facts
• 75% of all ED visits for heat-related illness
were among adults 18 to 64 years of age.
• Activities include both occupational (e.g.,
truck driving, warehouse, roofing,
landscaping) and recreational (e.g., jogging,
beach activities)
The EpiNotes Newsletter | Page 6
Public Health Concerns
and Costs of Monkey
Bites in North Carolina
Marilyn Goss Haskell, DVM
& Carl Williams, DVM
Introduction
In North Carolina, 17 non-human primate
(monkey) bites were investigated by the Communi-cable
Disease Branch over a five year period during
February 2011 to May 2015. Private ownership and
exhibitions of monkeys are a public health concern
for a number of reasons. Monkey behavior is un-predictable
with complex social organization within
each species that often results in bites or atacks to
owners and other persons that may approach
them. Bites and other injuries are associated with
an increased risk of transmission of infectious dis-eases,
some fatal to humans, with ensuing emo-tional
distress and medical costs to the patient.
Monkey atacks can also cause severe trauma and
potentially life-threatening physical injuries .
Legal Status
Importation of monkeys into the United States has
been federally restricted since 1975. Due to the
risk of infectious disease Monkeys may only be im-ported
for scientific or educational purposes
(htp://www.cdc.gov/importation/laws-and-regulations/
nonhuman-primates/nprm/
index.html).
This federal regulation, however, never addressed
ownership, possession and keeping of monkeys
already in the United States. That issue was left to
the states to develop legislation and has resulted in
a patchwork of state laws across the country. Exact
numbers are dificult to know but Born Free USA
and the Captive Wild Animal Protection Coalition
report that 21 states ban ownership or possession
of monkeys while 11 states (including North Caroli-na)
have no state law regulating their ownership.
The remainder of the states have some intermedi-ary
position allowing possession with appropriate
permiting (htp://www.bornfreeusa.org/
downloads/pdf/StateLawMaps_PRIMATES.pdf).
In North Carolina, legislation has been introduced
over the years to regulate exotic animals. NC Sen-ate
Bill 954 (1997) would have created a registry of
exotic animals for community awareness. NC Sen-ate
Bill 1032 (2005) directed a commission to study
the need to protect the public from the health and
safety risks posed by inherently dangerous animals
and also proposed a means to provide that protec-tion
to the public while protecting the welfare of
these animals. NC House Bill 554 (2015) was intro-duced
to prevent persons from possessing danger-ous
wild animals. This bill is currently under re-view.
Nonetheless there are two general statutes, NCGS
153A-131 and 160A-187, that allow a county or
city, respectively, to develop an ordinance to regu-late,
restrict, or prohibit the possession or harbor-ing
(within the county or city) of animals which are
dangerous to persons or property. An internet
search of county ordinances, conducted in Novem-ber
2014, revealed that about 42 of 100 N.C. coun-ties
have ordinances that restrict, either absolute-ly,
with permit or specified confinement, monkey
ownership.
Medical and Public Health Response
The human resources and time expended during a
monkey bite investigation are significant in com-parison
to a routine dog or cat bite investigation.
While very specific information about the disease
risks and human treatment protocol for dog and
cat bites is available, similar information about
treatment of monkey bites and disease risks is
often lacking. Investigations often involve federal,
state and local health department staf as well as
private veterinarians (See algorithm, page 8). En-actment
of comprehensive legislation that prohib-its
private monkey ownership would help eliminate
the risks and expense to the public and owners
associated with bite incidents and potential for
disease transmission and allow government re-sources
to be focused on core functions and pro-grams.
Rabies and Monkeys
Rabies has rarely been reported in monkeys in the
wild, and has only been sporadically associated
with cases in humans1. Like humans, rabies virus
infection in monkeys is rare. Monkeys born in cap-tivity
in the United States are considered low risk.
In Florida, between 1957 (the beginning of the rac-coon
rabies outbreak in Florida) and 1975, 636
monkeys and four chimpanzees were tested at
public health laboratories and all were negative2.
Free ranging, macaque monkeys that have been
introduced into Florida's Ocala Springs area, where
raccoon rabies is endemic, have never been diag-nosed
with rabies. However during 1991 to 1998, a
new Rabies virus variant has been identified in hu-mans
in Ceara, Brazil, that is not genetically or anti-genically
related to any bat or terrestrial variant in
the Americas. The Marmoset monkey appears to
be the reservoir1.
The EpiNotes Newsletter | Page 7
Herpes B Virus in Macaques
Old World monkeys of the genus Macaca
(Macaque monkeys) are of particular concern be-cause
they are
the natural host
of Macacine
herpesvirus (B
virus). B virus
infection is usu-ally
asympto-matic
in ma-caques
or may
present as a
mild herpes
simplex virus
infection, but
can cause a fatal infection in humans. From 30% to
80% of rhesus macaques are seropositive, the in-fection
is lifelong with intermitent reactivation
and shedding, particularly when the monkey is
stressed or immune-compromised3,4.
Herpes B Transmission and Infection in Humans
B virus is present in the saliva, feces, urine, genital
tissues and nervous tissue of infected macaques.
Transmission to humans occurs through bites,
scratches or when infected tissues or fluids contact
broken skin or mucous membranes. In research
facilities, infection has resulted from needle sticks
and cuts or scratches from sharp edges of contami-nated
cages. There has been only one human to
human transmission reported. B Virus infections
are rare in humans. The disease in humans may
present up to five weeks following exposure, how-ever,
the average incubation period is 3 days to 3
weeks. Death can occur in up to 80% of persons if
untreated5.
Recent incidents in NC
Three species of monkeys were responsible for 17
North Carolina bite-related incidents: 11 were Ma-caques
(genus Macaca); and six (three each) were
new world monkeys, Capuchins and Marmosets.
Eleven incidents involved privately-owned pets,
four occurred with monkeys housed at non-
Association of Zoos and Aquariums accredited
(AZA) zoos, and two were on exhibition.
Monetary Costs
Costs to the Patient
In addition to the large expenditures of time and
emotional distress to the patient for necessary
medical treatment, monkey bite incidents result in
a sizeable financial burden for both patient and
owner. In 2010, a survey of several North Carolina
emergency departments (ED) demonstrated an
average cost of approximately $10,000 for a com-plete
regimen of rabies PEP (NC DETECT data,
2009). According to the North Carolina State La-boratory
of Public Health, the cost of rabies biolog-ics
(in July 2015) for a 160 pound person (healthy
and not previously vaccinated) is $3,348 ($2,388
for human rabies immune globulin and $960 for
four vaccine doses ($240 each)). Prior estimates
revealed the mean total cost of a suspected human
rabies exposure to be $3,688, the direct costs per
case were $2,564, and the indirect costs were
$1,124 of that total. About one third of the total
cost for suspected human rabies exposure was
atributed to indirect costs (e.g., lost wages, trans-portation,
and day-care fees), most of which were
not reimbursable to the patient6. These costs are
not inclusive of ED expenses, wound care that may
be ongoing with possible surgery, and tetanus post
-exposure prophylaxis. Additionally, if the monkey
is a macaque monkey, the patient will have Herpes
B virus serology submited to the National Herpes
B Virus Laboratory at Georgia State University at
$60 per sample, and the cost of prescribed antiviral
drugs.
Costs to the Owner
A local health director can order a monkey to be
held in quarantine following a bite incident. Own-ers
may be required to pay boarding fees that
could range up to $50.00/day as well as B virus
serology at $60.00/sample.
Conclusion
While monkey bite incidents are rare; they typical-ly
lead to exorbitant medical and legal costs for
both victims and owners. Additionally, victims can
be exposed to herpes B virus, which has the poten-tial
to be fatal if untreated. Monkey ownership
poses serious health risks, above and beyond those
from dogs and cats, that must be considered.
References:
1. Favoreta SR, de Matos CC, Morais NB, Alves
Araujo FA,, de Matos NB. Rabies in Marmosets
(Callithrix jacchus), Ceara, Brazil. Emerg Inf Dis.
2001; 7 (6) .
2. Prather EC, Bigler WJ, Hof GL, Tomas JA. Rabies in
Florida: History, Status, Trends. 1975. Division of
Health, Jacksonville, FL, monograph number 14:96.
3. Ostrowski SR, Leslie MJ, Parrot T, et al. B-virus
from Pet Macaque Monkeys: An Emerging Threat in
the United States? Emerg Infect Dis 1998;4:117-
121.
4. Cohen JI, Davenport DS, Stewart JA, et al. Recom-mendations
for Prevention of and Therapy for Ex-posures
to B Virus (Cercopithecine Herpesvirus 1).
CID, 2002:35;1191-1203.
5. Badaruddin H, Schillinger JA, Herpesvirus Disease.
Herpesviral Encephalitis, Simioan B (B virus, simian
B disease, cercopithecine herpes virus 1). In: David
L. Heyman, MD, Editor. Control of Communicable
Diseases Manual. 20th Edition. Washington DC.
APHA, 2015, 281 - 284.
Courtesy CDC
The EpiNotes Newsletter | Page 8
Public Health Actions for Monkey Bites.
Algorithm represents minimum actions. Additional actions especially for Macaques and their victims may be required.
Actions for Human
Wound: wash with running water and soap for 15 minutes.
Mucous Membrane: flush with saline or water for 15 minutes.
LHD CD Nurse Refer Patient to Healthcare Provider
Healthcare Provider Assessments
1. Assess Need for Tetanus PEP1
2. Assess Need for Rabies PEP2·4
Is it a Macaque Monkey?
1. Assess risk of B virus exposure5•6
2. Consider B virus (ant ivira l) post-exposure
prophylaxis
3. Collect baseline serum for Herpes B virus
as soon as possible
4. Collect follow-up serum for Herpes B
virus 21 days after injury
5. Symptom watch 21 days post-bite
Actions for Monkey • -
LHD /Animal Control arranges a Veterinary Assessment Assess
rabies risk. Begin Secure Confinement
C Consult Communicable Disease Branch 919-733-3419 :J
Is it a Macaque Monkey?
Collect baseline serum for Herpes B
virus as close as possible to the time of
injury5•6
2. Collect follow·up serum for Herpes B j
virus 21 days after injury
Talan. Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med.
2004 Mar ;43(3): 305-14
2. Human Rabies Prevention -United States, 2008. MMWR. May 7, 2008 I 57; 1-26,28
3. Use of a Reduced {4-Dose) Vaccine Schedule for Postexposure Prophylaxis to Prevent Human Rabies: Recommendations of the Advisory Committee on Immunization
Practices, MMWR. March 19, 2010, Vol 59, I#RR-02
4. Consult Communicable Disease Branch {COB) for observation/testing options; 919-733-3419
l 5.
6.
Cohen. Recommendations for Prevention of and Therapy for Exposure to B Virus {Cercopithecine Herpesvirus 1). CID 2002:35 {15 November) : 1191-1203
CDC Herpes B Virus Website http://www.cdqzoy/heroesbyirus/
The EpiNotes Newsletter | Page 9
Vapor Intrusion from
Soil May Affect Resi-dential
Health
Beth Dittman, MS; Sandy Mort, MS; and Mer-cedes
Hernández-Pelletier, MPH
The Health Assessment, Consultation and Educa-tion
(HACE) Program within the Occupational and
Environmental Epidemiology Branch works to de-termine
public health impacts associated with ex-posures
to toxic substances released into the envi-ronment
throughout North Carolina. Exposure to
hazardous chemicals can occur via multiple path-ways,
but vapor intrusion has received increasing
atention as a potential route of human exposure
to hazardous volatile compounds. Vapor intrusion
(Figure 1) occurs when volatile chemicals present
in soil or groundwater emit vapors that migrate
through soil and into indoor spaces, such as
homes or commercial buildings. It is important to
determine if vapor intrusion is occurring when in-vestigating
sites with contaminated groundwater
plumes that extend near or under buildings. Re-cently,
HACE staf assessed the health risks to resi-dents
of an apartment complex in Greensboro, NC
in a suspected vapor intrusion situation.
A storage facility, located in Greensboro, NC
(Guilford County), is situated on the site of a for-mer
dairy operation. Prospective developers, in
collaboration with the N.C. Department of Environ-ment
and Natural Resources (DENR) discovered
groundwater contamination of trichloroethylene
(TCE) around the area of the former dairy opera-tion’s
fleet management facility. TCE is an industri-al
chemical often used as a degreasing agent, but is
also an ingredient in glues, paint removers, stain
removers, and other household products. It is clas-sified
by the U.S. Environmental Protection Agency
(EPA) as a human carcinogen with a mutagenic
mode of action, meaning that it can permanently
damage a person’s DNA. TCE may also cause ad-verse
health efects of the immune system, as well
as developmental efects in exposed fetuses. The
TCE-contaminated groundwater was found to ex-tend
beyond the property line and under a neigh-boring
apartment complex, resulting in potential
exposure for apartment residents. N.C. DENR initi-ated
a vapor intrusion investigation which revealed
a need for follow-up indoor air testing of the
ground-floor apartments. N.C. DENR asked HACE
staf to provide a TCE level in indoor air that is safe
for residents’ health. After reviewing the toxicolog-ical
literature, HACE staf provided an action level
above which it is recommended that people be
removed immediately from continuous exposure
to TCE in indoor air.
In May 2015, eight ground-floor apartment units
were tested for TCE levels in indoor air. N.C. DENR
contractors placed RadielloTM air samplers in each
apartment for seven days. Two apartments had
TCE levels higher than the HACE-recommended
action level. Immediately, U.S. EPA Emergency
Response program contractors took 24-hour in-door
air samples using SummaTM canisters to con-firm
the DENR findings, and placed activated car-bon
air filtration units in the two afected apart-ments.
Follow up sampling performed by U.S. EPA
contractors confirmed that the air filtration units
reduced the TCE concentrations below the action
level within a mater of days, ensuring that apart-ment
residents were no longer exposed to TCE in
their homes at levels that could adversely impact
their health.
A long term remedial strategy is needed to ensure
all apartment residents are protected from TCE
exposure through the vapor intrusion pathway. Air
filtration units are considered only an intermediate
remedial strategy, as the activated carbon filters
can become saturated and need to be replaced
periodically. U.S. EPA contractors are monitoring
air filtration unit performance and will conduct
maintenance on the units as necessary. HACE staf
continue to watch the situation closely and will
assess any new data that is collected to determine
if there is any threat to the health of the residents.
Reference:
US Environmental Protection Agency: htp://
www.epa.gov/oswer/vaporintrusion/basic.html
Photo (US EPA)
The EpiNotes Newsletter | Page 10
CD Program Alert
The Foodborne Team would like to share a few
important updates. We would also like to
thank you all for the hard work you do each
day in ensuring the health and well-being of
your communities and the people who live and
work in them! Recent updates to the North
Carolina Communicable Disease Manual are
highlighted here.
There has been a change to the case definition
for Campylobacter infection. The suspect case
classification is no longer included. The only
two classifications are now: confirmed, when
there is isolation (culture) of Campylobacter
spp. from a clinical specimen and probable,
when there is either an epi-linked case or de-tection
of the Campylobacter spp. from a clini-cal
specimen using a culture independent diag-nostic
test (CIDT, such as antigen test or PCR).
The Shigellosis LHD Disease Investigation Steps
and the Shigellosis Control Measures for Child-care
Centers and K-12 Schools have been up-dated
in the Communicable Disease Manual.
These changes are based on recommendations
in the 20th Edition of the Control of Communi-cable
Diseases Manual.
Please read through both of these documents.
If any questions arise after reading through the
updated documents, please call one of the
members of the Foodborne Team. Nicole Lee
can be reached at 919-715-1162 and Vanessa
Greene can be reached at 919-715-3685.
There are four specific conditions, Vibriosis,
Typhoid fever, Paratyphoid fever and Listerio-sis,
which require supplemental investigation
forms. The data collected on these forms are
should be completed in addition to the NC
EDSS part 2 form, and atached to the NC EDSS
event or faxed to the CD Branch. When these
forms need to be completed either a link to
the specific form will be in the dashboard or
the form itself will be in the atachments. The
forms can also be found on the CDC’s website.
Listeria: htp://www.cdc.gov/listeria/pdf/
ListeriaCaseReportFormOMB0920-
0004_alfalfa.pdf
Typhoid and paratyphoid: htp://
www.cdc.gov/nationalsurveillance/PDFs/typhi-surveillance-
form.pdf
Vibrio: htp://www.cdc.gov/
nationalsurveillance/PDFs/
CDC5279_COVISvibriosis.pdf
Regional Isolation and
Quarantine Workshops
PHPR is planning follow-up workshops to the
2013 Isolation and Quarantine regional train-ings
tentatively scheduled for November—
December, 2015. The objectives for the work-shop
include:
 Describe the legal authorities and jurisdic-tional
responsibilities of isolation and quar-antine.
 Illustrate lessons learned from the Measles
and Ebola outbreaks.
 Define and engage local, state and federal
partners involved in isolation and quaran-tine.
 Conduct and discuss a table-top exercise
involving communicable disease control
measures.
NEWS
The EpiNotes Newsletter | Page 11
Employee of the
Quarter: Shanae
Godley
Shanae is a preparedness planner for the Eastern
Regional Ofice in PHP&R. Her work has focused on
documenting progress by Local Health Departments
while providing them critical next steps in developing
their county programs to address the preparedness
capabilities. Shanae used her prior experience in
Science, Technology, Engineering, and Math (STEM)
education to develop a rubric which breaks down
critical next steps and documents progress. She
coordinated with planners in the other regional ofices
to develop the rubric for over 50 priority elements
within the 15 preparedness capabilities. Each of the
specialty capabilities required input from SME's such
as Epi/Surveillance, Medical Surge, Fatality
Management, Worker Safety, etc. She also
coordinated a team of
PHP&R planners,
PHP&R SMEs and local
health department
preparedness
coordinators to review
the rubric for it’s
usefulness and ease of
completion. Rubric
roll-out required
several days of training
which was conducted
in conjunction with the
Medical
Countermeasure
Operational Readiness
Review roll-out.
The first set of data
was collected in
February 2015 and her team is currently analyzing the
results. Local Health Departments will continuously
use the rubric to develop their local programs and see
what next steps need to be taken. The reports will be
used to identify priority gaps and places to focus
program assistance.
The rubric has resulted in the first real-time
assessment of the status of preparedness in the state.
Because it is a standard model, it is being looked at by
other partners in the state as a potential tool for their
own adaptation and has created interest at CDC for
national use.
Most importantly, because of her vision and
leadership on this project, the activity has crystalized
the team of planners in PHP&R and has nurtured
relationships with the local health department staf.
This has increased morale, supported professional
growth and resulted in a sense of accomplishment by
everyone involved.
Pictured from L-R: Dr. Julie Casani, Shanae Godley, and Dr. Megan Davies
Dr. Jessica
Rinsky joins the
Communicable
Disease Branch
as the 35th Epi-demic
Intelli-gence
Service
(EIS) Officer.
Jessica Rinsky, PhD is
our newest EIS Officer
to be assigned from
CDC to the Medical Consultation Unit, Communica-ble
Disease Branch. Jessica recently completed her
PhD in Epidemiology from the University of North
Carolina Gilling's School of Global Public Health. Dur-ing
her two-year fellowship, she will monitor surveil-lance
data, conduct outbreak investigations, and
support local health departments by serving as an on
-call epidemiologist.
Davidson County Salmonellosis
Outbreak One of Largest in State
History.
During June 2015, a popular BBQ restaurant, Tarheel
Q, located in Lexington, NC was the source of
Salmonella typhimurium infections for more than
275 patrons. A joint investigation identified
improperly cooked pork product as the likely vehicle
for disease transmission. Pork product tested at the
State Laboratory of Public Health demonstrated an
identical Salmonella strain with testing performed
on human cases. After control measures were
implemented and two incubation periods passed,
the outbreak oficially ended on August 8, 2015.
The EpiNotes Newsletter | Page 12
EpiNotes Editor: Aaron Fleischauer, PhD MSPH
State of North Carolina │ North Carolina Department of Health and Human Services
North Carolina Division of Public Health │ Epidemiology Section
www.ncdhhs.gov
N.C. DHHS is an equal opportunity employer and provider. 7/13
Communicable Disease Branch
(Epi 24/7 on-call)
919-733-3419
HIV/STD Program
919-733-7301
TB Program
919-733-3419
Occupational & Environmental and Epidemiology Branch
919-707-5900
Public Health Preparedness and Response
919-715-0919
PHPR Emergency 24/7
919-820-0520
Rabies Emergency
(Nights, Weekends, Holidays)
919-733-3419
State Laboratory of Public Health
919-733-7834
Courtesy of NC.gov

The EpiNotes Newsletter | Page
Summer 2015
Cover: Estuarine shoreline (Courtesy of DENR)
PAGE
Vibriosis in North Carolina: 1997—2014 2
Clinical Impact of the June 2015 Heatwave 5
Concerns and Cost of Monkey Bites 6
Vapor Intrusion and Residential Health 9
News and Events 10
Employee of the Quarter 11
Contact Us 12
The
EpiNotes
Newsletter
North Carolina Department of
Health and Human Services
The EpiNotes Newsletter | Page 2
V ibrio infections are the leading cause of
deaths linked to under-cooked seafood
in the United States. There are more
than 200 recognized species of Vibrios,
however, in the United States, only a few are
known to cause disease in humans, vulnificus,
parahaemolyticus and alginolyticus
being the major ones.
Infections are often
acquired from
exposure to sea water
or eating raw oysters
because the bacteria
lodges in the tissues of
mollusks such as oysters,
clams, mussels and crabs.
Typically, the incubation
period is 4 to 92 hours. In the
United States, vibrio infections
are nationally notifiable and
account for an estimated 80,000 illnesses, 500
hospitalizations and 100 deaths each year1,2.
In North Carolina, disease reports are categorized
into Vibrio vulnificus infection and vibrio other
infection (other than vulnificus and toxigenic
cholerae). Vibrio species can cause a variety of
clinical syndromes, including gastroenteritis,
wound infection, fever and septicemia. By
decreasing order of occurrence, the three distinct
syndromes of V. vulnificus infections are wound
infection, septicemia and GI tract infections3,
whereas, the three distinct syndromes of V.
parahaemolyticus infections are GI tract infections,
wound infection and septicemia4. Wound infection
is severe in people with liver disease or
immunodeficiency. V. vulnificus
infections often occurs following
wound exposure to contaminated
water and most V.
parahaemolyticus cases report
consumption of raw or
undercooked seafood.
The clinical case definition
used for surveillance
purposes is an infection of
variable severity
characterized by diarrhea
and vomiting, primary
septicemia, or wound infections. A
confirmed case meets the clinical case definition
with isolation of pathogen from a clinical
specimen; a probable case is a clinically-compatible
case that is linked to a confirmed case but does not
meet the laboratory criteria for diagnosis.
We extracted vibriosis case data for 1997 to 2014
from NC EDSS (North Carolina Electronic Disease
Surveillance System) to obtain demographic,
clinical and epidemiologic information. The NC
EDSS investigation form includes data on
demographics (age, sex, race, county of residence),
clinical information (symptoms, duration of illness,
pre-existing medical conditions such as liver
disease, diabetes and other underlying conditions,
whether the patient was hospitalized and health
outcomes) and epidemiologic information (recent
travel information, seafood exposure and contact
with water). Data were analyzed using SPSS 19. Chi
-square tests were used to compare the health
outcomes and risk factor proportions among V.
vulnificus and other V. spp.
A case was defined as foodborne if the patient
reported seafood consumption/ handling as the
only exposure and as waterborne if the patient
reported water exposure (with or without pre-existing
or sustained wound(s)) as the only
exposure.
Over a span of 18 years (1997 – 2014), a total of
334 cases of vibriosis were reported to local health
departments. Of these, 72% were male, 52% were
over 50 years of age, and 81% were white, non-
Hispanic. Most cases (54%) were residents of the
Coastal region of the state, followed by Mountain
(37%), and Piedmont (10%). The most frequent
species identified by culture were V.
parahaemolyticus, (29%), V. vulnificus (26%), V.
alginolyticus (18%) and V. fluvialis (9%) followed by
other less common species. Fever, nausea and
cellulitis were more likely with vulnificus infections
and fever, nausea, diarrhea, abdominal cramps
were more characteristic of parahaemolyticus
infections. Diarrhea was significantly more
common among cases with parahaemolyticus
(47%) infections when compared with vulnificus
cases (24%; p<0.05). (Table 1).
The Epidemiology of Vibriosis Infections
in North Carolina: 1997—2014
Mounika Bazar; Aaron Fleischauer, PhD; Chris Pierson; Nirmalla Barros, PhD; and Carl Williams, DVM.
Photo (CDC)
The EpiNotes Newsletter | Page 3
Pre-existing liver disease and immune-suppressing
conditions were significantly more common among
persons with V. vulnificus infections (22% versus
3%; 44% versus 18%; respectively p<0.05)
compared with person with V. parahaemolyticus
infections. No difference was observed in persons
with diabetes. Hospitalization was also more
common among cases with V. vulnificus (56%)
infections compared with V. parahaemolyticus
(45%) and other species. Among the 19 deaths, 18
occurred in patients with V. vulnificus infections
(case fatality rate of 21%) and one in patient with
V. parahaemolyticus infection (case fatality rate of
1%). Hospitalizations and case-fatality rates were
observed to be lower than the national rates.
Other risk factors were mostly similar when
comparing V. vulnificus with V. parahaemolyticus
and consistent with national data: 54% of cases
were foodborne and 37% were non-foodborne
(unknown in 9%). Water exposure with pre-existing
or sustained wound(s) difered significantly
though, with 30% in vulnificus infections versus
20% among persons with parahaemolyticus
infections, p< 0.05. No significant diference was
found when considering water exposure alone (7%
in both), wound infection (7% versus 4.2%), shell
fish consumption/ handling (45% versus 52%),
finfish consumption/ handling (5% versus 2%).
(Table 2).
Vibriosis is seasonal. Incidence peaks annually in
June, July and August; twice as many cases occur in
summer than non-summer months and a second
peak was observed in November (Figure 1). There
appears to be a very modest increasing trend over
the study period. In 2012 however, a marked
increase in incidence was observed for reasons
unknown. (Figure 2).
Discussion:
While reported vibriosis infections are relatively
rare in North Carolina, the illness can be serious
and is often preventable. In North Carolina as
elsewhere, V. vulnificus has a higher case fatality
rate than other vibrio species; however the case
fatality rate observed in North Carolina was lower
than that reported in national averages (20% v.
32%). Among reported cases, older white males
tend to be more at risk for infection, possibly as a
result of higher risk associated with occupation or
dietary choices. Pre-existence of co-morbid
conditions likely increases the risk of severe
vibriosis infection, particularly diabetes, liver
disease or other immune-suppressing conditions
(N. A. Daniels, 2011). Co-morbid liver disease and
immune suppressing conditions increase the risk of
hospitalization and death. V. vulnificus infections
are known to be more severe than other species,
but nearly 43% of all reported vibriosis cases were
hospitalized.
The seasonality of vibriosis suggests that marine
and estuary water temperatures are an important
factor in the epidemiology of the disease. It is also
associated with a behavioral-dependent exposure;
an increased number of people take their coastal
vacation in the summer months. Clinical
information for cases before 2008 was not
available for this study, as web-based surveillance
was not introduced until 2008. Data completeness
has significantly improved after the
implementation of NC EDSS, enhancing our ability
to characterize reportable diseases. However our
surveillance has some limitations. For example,
many potential cases do not receive diagnostic
testing which leads to under-reporting particularly
for those Vibrio species that cause milder illness.
Demographics N=334 %
Age:
0-10
11-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
29
24
24
35
49
52
57
46
18
8.7
7.2
7.2
10.5
14.7
15.6
17.1
13.7
5.3
Gender:
Male
Female
Unknown
240
91
3
71.8
27.3
0.9
Race/Ethnicity:
White (NH)
Hispanic
African American
Asian
American Indian
Unknown/other
269
5
29
8
5
18
80.6
1.5
8.7
2.4
1.4
5.4
County of Residence:
Coastal
Piedmont
Mountain
179
33
122
53.6
9.9
36.5
Vibrio subtype:
parahaemolyticus
vulnificus
alginolyticus
fluvialis
hollisae
mimicus
damsela
cholerae
cholera non O1
harveyi
unknown
96
86
61
26
13
8
5
5
14
2
18
28.7
25.8
18.3
7.8
3.9
2.4
1.5
1.5
4.2
0.5
5.4
Hospitalized? (Yes) 143 42.8
Died? (Yes)
19
5.7
Table 1. Demographics among persons with vibriosis.
The EpiNotes Newsletter | Page 4
Recommendations: Infections caused by Vibrio
species can be prevented by thoroughly cooking
sea food, especially oysters and clams. Persons
who are immunocompromised, especially those
with liver disease or HIV, should avoid eating raw
or undercooked shell fish.
Wound infections can be prevented by appropriate
wound care and avoiding exposure of open
wounds to sea water and marine environments.
Fishermen and persons handling shell fish should
wear protective gloves to decrease the risk of
puncture wounds.
Restaurants should always provide food advisories
to their customers about undercooked or raw sea
food. People should be educated about vibriosis
symptoms and be encouraged to inform their
health care provider if they become ill following
estuarine and/or shellfish exposure.
References:
1. Centers for Disease Control and Prevention.
Retrieved June 15, 2015, from htp://www.cdc.gov/
vibrio/index.html
2. Centers for Disease Control and Prevention.
National Enteric Disease Surveillance: COVIS annual
summary, 2012. Retrieved June 15, 2015, from
htp://www.cdc.gov/ncezid/dfwed/pdfs/covis-annual-
report-2012-508c.pdf
3. Daniels, NA. Vibrio vulnificus oysters: pearls and
perils. Clin Infect Dis. 2011. 15; 52(6): 788–792.
4. N. A. Daniels, L. MacKinnon, R. Bishop, S.
Altekruse, B. Ray, R. M. Hammond, S. Thompson, S.
Wilson, N. H. Bean, P. M. Grifin, et al. Vibrio
parahaemolyticus infections in the United States,
1973-1998. J Infect Dis. 2000. 181(5): 1661–1666.
Risk Factor V. vulnifi-cus
(N=86)
V. parahaemolyti-cus
(N= 96)
V. spp. Other
(N=134)
Compar-ison
Water exposure
6 (7%)
7 (7.3%) 24 (18%) NS
Water exposure with
pre-existing wound
26 (30.2%) 19 (19.8%) 23 (17%) p<0.05
Presence of wound (no exposure
to risk factors)
6 (7%) 4 (4.2%) 8 (6%) NS
Shell fish consumption/handling 39 (45.4%) 50 (52.1%) 46 (34%) NS
Fin fish consumption/handling 4 (4.7%) 2 (2.1%) 3 (2%) NS
Diabetes 15 (17.4%) 13 (13.5%) 14 (11%) NS
Liver disease 19 (22.1%) 3 (3.1%) 1 (0.8%) p<0.05
Immuno-suppressed 38 (44.2%) 17 (17.8%) 36 (27%) p<0.05
Table 2. Epidemiologic Risk Factors and Vibriosis by Species
Figure 2. Vibriosis cases reported by year of diagnosis,
North Carolina, 1997 – 2014.
Figure 1. Seasonal distribution of Vibriosis cases by month
of diagnosis, North Carolina, 1997 – 2014.
The EpiNotes Newsletter | Page 5
June 2015 Heatwave
Makes Big Impact
Lauren Thie, MSPH & Sara Smith, MA
Heatwaves are common in North Carolina most
summers. During June 15-24, 2015 there were 10
consecutive days of heat advisories
(heat index of 105°F or greater)
issued by the U.S. National Weath-er
Service ofices serving North Car-olina.
Over the 10 day heat wave,
917 emergency department (ED)
visits for potential heat-related ill-ness
were observed. The majority
of ED visits occurred in the Pied-mont
and Coastal regions. This
number of ED visits far exceeded
what is expected during a typical
summer period, and was much
greater than the same period over
the previous two summers. A dash-board
was developed in response
to highlight the clinical impact the
heatwave had on North Carolinians
(Figure 1).
Prevention: Heat-related illness can
be prevented if proper precautions are fol-lowed.
Some evidence-based messages include1:
 Increase fluid intake
 Reduce activity during the hotest part of the
day (typically 11 am – 4pm)
 Spend some time in air-conditioning
 Consult your physician if you take medications
that reduce the body’s ability to cool itself
(e.g., blood pressure medications, psychologi-cal
medications).
Acclimatization plays an important role in health
and played a major role in this year’s heatwave. It
takes the body about 7-14 days to acclimate to
high temperatures. Since this year’s heatwave
came in early June, prior to any periods of high
temperatures, it was especially dangerous. Accli-matization
also plays an important role in health
protection for those in outdoor professions. Those
new to the job or recently returning from leave will
need to acclimate to the heat before working the
same amounts as those who have been working
outside continually this summer2.
Research indicates the combination of poor air
quality and heat exposure creates particularly dan-gerous
health impacts, more so than either threat
individually. Typically, days with poor air quality
are days with high heat. In response, heat illness
messaging now includes information on poor air
quality. In collaboration with the North Carolina
Department of Environment and Natural Re-sources,
Division of Air Quality, a flyer was devel-oped
to outline ways older adults can protect their
health from air pollution and
heat. Approximately 2,000 flyers
have been distributed to older citi-zens
(over the age of 65) and those
adults living with disabilities by the
Department of Health and Human
Services, Division of Aging & Adult
Services in conjunction with Opera-tion
Fan Heat Relief.
Each year from May through Sep-tember,
weekly heat-related illness
reports are distributed to our key
stakeholders and posted on the
OEEB website. To join this listserv,
please contact Lauren Thie at lau-ren.
thie@dhhs.nc.gov.
For more information on preventing
heat-related health issues, please
visit: htp://publichealth.nc.gov/
chronicdiseaseandinjury/heat.htm
References
1. Hajat, S., O’Connor, M., & Kosatsky, T. (2010).
Health efects of hot weather: from awareness of
risk factors to efective health protection. The Lan-cet,
375, 857-863.
2. Arbury, S., Jacklitsch, B., Farquah, O., Hodgson, M.,
Lamson, G., Martin, H., & Profit, A. (2014). Heat
illness and death among workers – United States,
2012-2013. MMWR, 63(31), 661-5.
Heat Related Illness Dashboard
June 15 – 22, 2015
Total Emergency Department
visits for heat-related illness
917
Percent of Emergency
Department visits Hospitalized
10%
Averagemaximum heat index
during this timeframe (RDU
Airport)
103F
Recommendations
• Drink fluids
• Spend some time in air conditioning
• Reduce activity between 11 am – 4 pm
• Consult your doctor if you take medications
that impact the body’s ability to lose heat
Proportion of ED Visits attributed to Heat Related Illness
2015 compared with previous 2 years
Data Facts
• 75% of all ED visits for heat-related illness
were among adults 18 to 64 years of age.
• Activities include both occupational (e.g.,
truck driving, warehouse, roofing,
landscaping) and recreational (e.g., jogging,
beach activities)
The EpiNotes Newsletter | Page 6
Public Health Concerns
and Costs of Monkey
Bites in North Carolina
Marilyn Goss Haskell, DVM
& Carl Williams, DVM
Introduction
In North Carolina, 17 non-human primate
(monkey) bites were investigated by the Communi-cable
Disease Branch over a five year period during
February 2011 to May 2015. Private ownership and
exhibitions of monkeys are a public health concern
for a number of reasons. Monkey behavior is un-predictable
with complex social organization within
each species that often results in bites or atacks to
owners and other persons that may approach
them. Bites and other injuries are associated with
an increased risk of transmission of infectious dis-eases,
some fatal to humans, with ensuing emo-tional
distress and medical costs to the patient.
Monkey atacks can also cause severe trauma and
potentially life-threatening physical injuries .
Legal Status
Importation of monkeys into the United States has
been federally restricted since 1975. Due to the
risk of infectious disease Monkeys may only be im-ported
for scientific or educational purposes
(htp://www.cdc.gov/importation/laws-and-regulations/
nonhuman-primates/nprm/
index.html).
This federal regulation, however, never addressed
ownership, possession and keeping of monkeys
already in the United States. That issue was left to
the states to develop legislation and has resulted in
a patchwork of state laws across the country. Exact
numbers are dificult to know but Born Free USA
and the Captive Wild Animal Protection Coalition
report that 21 states ban ownership or possession
of monkeys while 11 states (including North Caroli-na)
have no state law regulating their ownership.
The remainder of the states have some intermedi-ary
position allowing possession with appropriate
permiting (htp://www.bornfreeusa.org/
downloads/pdf/StateLawMaps_PRIMATES.pdf).
In North Carolina, legislation has been introduced
over the years to regulate exotic animals. NC Sen-ate
Bill 954 (1997) would have created a registry of
exotic animals for community awareness. NC Sen-ate
Bill 1032 (2005) directed a commission to study
the need to protect the public from the health and
safety risks posed by inherently dangerous animals
and also proposed a means to provide that protec-tion
to the public while protecting the welfare of
these animals. NC House Bill 554 (2015) was intro-duced
to prevent persons from possessing danger-ous
wild animals. This bill is currently under re-view.
Nonetheless there are two general statutes, NCGS
153A-131 and 160A-187, that allow a county or
city, respectively, to develop an ordinance to regu-late,
restrict, or prohibit the possession or harbor-ing
(within the county or city) of animals which are
dangerous to persons or property. An internet
search of county ordinances, conducted in Novem-ber
2014, revealed that about 42 of 100 N.C. coun-ties
have ordinances that restrict, either absolute-ly,
with permit or specified confinement, monkey
ownership.
Medical and Public Health Response
The human resources and time expended during a
monkey bite investigation are significant in com-parison
to a routine dog or cat bite investigation.
While very specific information about the disease
risks and human treatment protocol for dog and
cat bites is available, similar information about
treatment of monkey bites and disease risks is
often lacking. Investigations often involve federal,
state and local health department staf as well as
private veterinarians (See algorithm, page 8). En-actment
of comprehensive legislation that prohib-its
private monkey ownership would help eliminate
the risks and expense to the public and owners
associated with bite incidents and potential for
disease transmission and allow government re-sources
to be focused on core functions and pro-grams.
Rabies and Monkeys
Rabies has rarely been reported in monkeys in the
wild, and has only been sporadically associated
with cases in humans1. Like humans, rabies virus
infection in monkeys is rare. Monkeys born in cap-tivity
in the United States are considered low risk.
In Florida, between 1957 (the beginning of the rac-coon
rabies outbreak in Florida) and 1975, 636
monkeys and four chimpanzees were tested at
public health laboratories and all were negative2.
Free ranging, macaque monkeys that have been
introduced into Florida's Ocala Springs area, where
raccoon rabies is endemic, have never been diag-nosed
with rabies. However during 1991 to 1998, a
new Rabies virus variant has been identified in hu-mans
in Ceara, Brazil, that is not genetically or anti-genically
related to any bat or terrestrial variant in
the Americas. The Marmoset monkey appears to
be the reservoir1.
The EpiNotes Newsletter | Page 7
Herpes B Virus in Macaques
Old World monkeys of the genus Macaca
(Macaque monkeys) are of particular concern be-cause
they are
the natural host
of Macacine
herpesvirus (B
virus). B virus
infection is usu-ally
asympto-matic
in ma-caques
or may
present as a
mild herpes
simplex virus
infection, but
can cause a fatal infection in humans. From 30% to
80% of rhesus macaques are seropositive, the in-fection
is lifelong with intermitent reactivation
and shedding, particularly when the monkey is
stressed or immune-compromised3,4.
Herpes B Transmission and Infection in Humans
B virus is present in the saliva, feces, urine, genital
tissues and nervous tissue of infected macaques.
Transmission to humans occurs through bites,
scratches or when infected tissues or fluids contact
broken skin or mucous membranes. In research
facilities, infection has resulted from needle sticks
and cuts or scratches from sharp edges of contami-nated
cages. There has been only one human to
human transmission reported. B Virus infections
are rare in humans. The disease in humans may
present up to five weeks following exposure, how-ever,
the average incubation period is 3 days to 3
weeks. Death can occur in up to 80% of persons if
untreated5.
Recent incidents in NC
Three species of monkeys were responsible for 17
North Carolina bite-related incidents: 11 were Ma-caques
(genus Macaca); and six (three each) were
new world monkeys, Capuchins and Marmosets.
Eleven incidents involved privately-owned pets,
four occurred with monkeys housed at non-
Association of Zoos and Aquariums accredited
(AZA) zoos, and two were on exhibition.
Monetary Costs
Costs to the Patient
In addition to the large expenditures of time and
emotional distress to the patient for necessary
medical treatment, monkey bite incidents result in
a sizeable financial burden for both patient and
owner. In 2010, a survey of several North Carolina
emergency departments (ED) demonstrated an
average cost of approximately $10,000 for a com-plete
regimen of rabies PEP (NC DETECT data,
2009). According to the North Carolina State La-boratory
of Public Health, the cost of rabies biolog-ics
(in July 2015) for a 160 pound person (healthy
and not previously vaccinated) is $3,348 ($2,388
for human rabies immune globulin and $960 for
four vaccine doses ($240 each)). Prior estimates
revealed the mean total cost of a suspected human
rabies exposure to be $3,688, the direct costs per
case were $2,564, and the indirect costs were
$1,124 of that total. About one third of the total
cost for suspected human rabies exposure was
atributed to indirect costs (e.g., lost wages, trans-portation,
and day-care fees), most of which were
not reimbursable to the patient6. These costs are
not inclusive of ED expenses, wound care that may
be ongoing with possible surgery, and tetanus post
-exposure prophylaxis. Additionally, if the monkey
is a macaque monkey, the patient will have Herpes
B virus serology submited to the National Herpes
B Virus Laboratory at Georgia State University at
$60 per sample, and the cost of prescribed antiviral
drugs.
Costs to the Owner
A local health director can order a monkey to be
held in quarantine following a bite incident. Own-ers
may be required to pay boarding fees that
could range up to $50.00/day as well as B virus
serology at $60.00/sample.
Conclusion
While monkey bite incidents are rare; they typical-ly
lead to exorbitant medical and legal costs for
both victims and owners. Additionally, victims can
be exposed to herpes B virus, which has the poten-tial
to be fatal if untreated. Monkey ownership
poses serious health risks, above and beyond those
from dogs and cats, that must be considered.
References:
1. Favoreta SR, de Matos CC, Morais NB, Alves
Araujo FA,, de Matos NB. Rabies in Marmosets
(Callithrix jacchus), Ceara, Brazil. Emerg Inf Dis.
2001; 7 (6) .
2. Prather EC, Bigler WJ, Hof GL, Tomas JA. Rabies in
Florida: History, Status, Trends. 1975. Division of
Health, Jacksonville, FL, monograph number 14:96.
3. Ostrowski SR, Leslie MJ, Parrot T, et al. B-virus
from Pet Macaque Monkeys: An Emerging Threat in
the United States? Emerg Infect Dis 1998;4:117-
121.
4. Cohen JI, Davenport DS, Stewart JA, et al. Recom-mendations
for Prevention of and Therapy for Ex-posures
to B Virus (Cercopithecine Herpesvirus 1).
CID, 2002:35;1191-1203.
5. Badaruddin H, Schillinger JA, Herpesvirus Disease.
Herpesviral Encephalitis, Simioan B (B virus, simian
B disease, cercopithecine herpes virus 1). In: David
L. Heyman, MD, Editor. Control of Communicable
Diseases Manual. 20th Edition. Washington DC.
APHA, 2015, 281 - 284.
Courtesy CDC
The EpiNotes Newsletter | Page 8
Public Health Actions for Monkey Bites.
Algorithm represents minimum actions. Additional actions especially for Macaques and their victims may be required.
Actions for Human
Wound: wash with running water and soap for 15 minutes.
Mucous Membrane: flush with saline or water for 15 minutes.
LHD CD Nurse Refer Patient to Healthcare Provider
Healthcare Provider Assessments
1. Assess Need for Tetanus PEP1
2. Assess Need for Rabies PEP2·4
Is it a Macaque Monkey?
1. Assess risk of B virus exposure5•6
2. Consider B virus (ant ivira l) post-exposure
prophylaxis
3. Collect baseline serum for Herpes B virus
as soon as possible
4. Collect follow-up serum for Herpes B
virus 21 days after injury
5. Symptom watch 21 days post-bite
Actions for Monkey • -
LHD /Animal Control arranges a Veterinary Assessment Assess
rabies risk. Begin Secure Confinement
C Consult Communicable Disease Branch 919-733-3419 :J
Is it a Macaque Monkey?
Collect baseline serum for Herpes B
virus as close as possible to the time of
injury5•6
2. Collect follow·up serum for Herpes B j
virus 21 days after injury
Talan. Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med.
2004 Mar ;43(3): 305-14
2. Human Rabies Prevention -United States, 2008. MMWR. May 7, 2008 I 57; 1-26,28
3. Use of a Reduced {4-Dose) Vaccine Schedule for Postexposure Prophylaxis to Prevent Human Rabies: Recommendations of the Advisory Committee on Immunization
Practices, MMWR. March 19, 2010, Vol 59, I#RR-02
4. Consult Communicable Disease Branch {COB) for observation/testing options; 919-733-3419
l 5.
6.
Cohen. Recommendations for Prevention of and Therapy for Exposure to B Virus {Cercopithecine Herpesvirus 1). CID 2002:35 {15 November) : 1191-1203
CDC Herpes B Virus Website http://www.cdqzoy/heroesbyirus/
The EpiNotes Newsletter | Page 9
Vapor Intrusion from
Soil May Affect Resi-dential
Health
Beth Dittman, MS; Sandy Mort, MS; and Mer-cedes
Hernández-Pelletier, MPH
The Health Assessment, Consultation and Educa-tion
(HACE) Program within the Occupational and
Environmental Epidemiology Branch works to de-termine
public health impacts associated with ex-posures
to toxic substances released into the envi-ronment
throughout North Carolina. Exposure to
hazardous chemicals can occur via multiple path-ways,
but vapor intrusion has received increasing
atention as a potential route of human exposure
to hazardous volatile compounds. Vapor intrusion
(Figure 1) occurs when volatile chemicals present
in soil or groundwater emit vapors that migrate
through soil and into indoor spaces, such as
homes or commercial buildings. It is important to
determine if vapor intrusion is occurring when in-vestigating
sites with contaminated groundwater
plumes that extend near or under buildings. Re-cently,
HACE staf assessed the health risks to resi-dents
of an apartment complex in Greensboro, NC
in a suspected vapor intrusion situation.
A storage facility, located in Greensboro, NC
(Guilford County), is situated on the site of a for-mer
dairy operation. Prospective developers, in
collaboration with the N.C. Department of Environ-ment
and Natural Resources (DENR) discovered
groundwater contamination of trichloroethylene
(TCE) around the area of the former dairy opera-tion’s
fleet management facility. TCE is an industri-al
chemical often used as a degreasing agent, but is
also an ingredient in glues, paint removers, stain
removers, and other household products. It is clas-sified
by the U.S. Environmental Protection Agency
(EPA) as a human carcinogen with a mutagenic
mode of action, meaning that it can permanently
damage a person’s DNA. TCE may also cause ad-verse
health efects of the immune system, as well
as developmental efects in exposed fetuses. The
TCE-contaminated groundwater was found to ex-tend
beyond the property line and under a neigh-boring
apartment complex, resulting in potential
exposure for apartment residents. N.C. DENR initi-ated
a vapor intrusion investigation which revealed
a need for follow-up indoor air testing of the
ground-floor apartments. N.C. DENR asked HACE
staf to provide a TCE level in indoor air that is safe
for residents’ health. After reviewing the toxicolog-ical
literature, HACE staf provided an action level
above which it is recommended that people be
removed immediately from continuous exposure
to TCE in indoor air.
In May 2015, eight ground-floor apartment units
were tested for TCE levels in indoor air. N.C. DENR
contractors placed RadielloTM air samplers in each
apartment for seven days. Two apartments had
TCE levels higher than the HACE-recommended
action level. Immediately, U.S. EPA Emergency
Response program contractors took 24-hour in-door
air samples using SummaTM canisters to con-firm
the DENR findings, and placed activated car-bon
air filtration units in the two afected apart-ments.
Follow up sampling performed by U.S. EPA
contractors confirmed that the air filtration units
reduced the TCE concentrations below the action
level within a mater of days, ensuring that apart-ment
residents were no longer exposed to TCE in
their homes at levels that could adversely impact
their health.
A long term remedial strategy is needed to ensure
all apartment residents are protected from TCE
exposure through the vapor intrusion pathway. Air
filtration units are considered only an intermediate
remedial strategy, as the activated carbon filters
can become saturated and need to be replaced
periodically. U.S. EPA contractors are monitoring
air filtration unit performance and will conduct
maintenance on the units as necessary. HACE staf
continue to watch the situation closely and will
assess any new data that is collected to determine
if there is any threat to the health of the residents.
Reference:
US Environmental Protection Agency: htp://
www.epa.gov/oswer/vaporintrusion/basic.html
Photo (US EPA)
The EpiNotes Newsletter | Page 10
CD Program Alert
The Foodborne Team would like to share a few
important updates. We would also like to
thank you all for the hard work you do each
day in ensuring the health and well-being of
your communities and the people who live and
work in them! Recent updates to the North
Carolina Communicable Disease Manual are
highlighted here.
There has been a change to the case definition
for Campylobacter infection. The suspect case
classification is no longer included. The only
two classifications are now: confirmed, when
there is isolation (culture) of Campylobacter
spp. from a clinical specimen and probable,
when there is either an epi-linked case or de-tection
of the Campylobacter spp. from a clini-cal
specimen using a culture independent diag-nostic
test (CIDT, such as antigen test or PCR).
The Shigellosis LHD Disease Investigation Steps
and the Shigellosis Control Measures for Child-care
Centers and K-12 Schools have been up-dated
in the Communicable Disease Manual.
These changes are based on recommendations
in the 20th Edition of the Control of Communi-cable
Diseases Manual.
Please read through both of these documents.
If any questions arise after reading through the
updated documents, please call one of the
members of the Foodborne Team. Nicole Lee
can be reached at 919-715-1162 and Vanessa
Greene can be reached at 919-715-3685.
There are four specific conditions, Vibriosis,
Typhoid fever, Paratyphoid fever and Listerio-sis,
which require supplemental investigation
forms. The data collected on these forms are
should be completed in addition to the NC
EDSS part 2 form, and atached to the NC EDSS
event or faxed to the CD Branch. When these
forms need to be completed either a link to
the specific form will be in the dashboard or
the form itself will be in the atachments. The
forms can also be found on the CDC’s website.
Listeria: htp://www.cdc.gov/listeria/pdf/
ListeriaCaseReportFormOMB0920-
0004_alfalfa.pdf
Typhoid and paratyphoid: htp://
www.cdc.gov/nationalsurveillance/PDFs/typhi-surveillance-
form.pdf
Vibrio: htp://www.cdc.gov/
nationalsurveillance/PDFs/
CDC5279_COVISvibriosis.pdf
Regional Isolation and
Quarantine Workshops
PHPR is planning follow-up workshops to the
2013 Isolation and Quarantine regional train-ings
tentatively scheduled for November—
December, 2015. The objectives for the work-shop
include:
 Describe the legal authorities and jurisdic-tional
responsibilities of isolation and quar-antine.
 Illustrate lessons learned from the Measles
and Ebola outbreaks.
 Define and engage local, state and federal
partners involved in isolation and quaran-tine.
 Conduct and discuss a table-top exercise
involving communicable disease control
measures.
NEWS
The EpiNotes Newsletter | Page 11
Employee of the
Quarter: Shanae
Godley
Shanae is a preparedness planner for the Eastern
Regional Ofice in PHP&R. Her work has focused on
documenting progress by Local Health Departments
while providing them critical next steps in developing
their county programs to address the preparedness
capabilities. Shanae used her prior experience in
Science, Technology, Engineering, and Math (STEM)
education to develop a rubric which breaks down
critical next steps and documents progress. She
coordinated with planners in the other regional ofices
to develop the rubric for over 50 priority elements
within the 15 preparedness capabilities. Each of the
specialty capabilities required input from SME's such
as Epi/Surveillance, Medical Surge, Fatality
Management, Worker Safety, etc. She also
coordinated a team of
PHP&R planners,
PHP&R SMEs and local
health department
preparedness
coordinators to review
the rubric for it’s
usefulness and ease of
completion. Rubric
roll-out required
several days of training
which was conducted
in conjunction with the
Medical
Countermeasure
Operational Readiness
Review roll-out.
The first set of data
was collected in
February 2015 and her team is currently analyzing the
results. Local Health Departments will continuously
use the rubric to develop their local programs and see
what next steps need to be taken. The reports will be
used to identify priority gaps and places to focus
program assistance.
The rubric has resulted in the first real-time
assessment of the status of preparedness in the state.
Because it is a standard model, it is being looked at by
other partners in the state as a potential tool for their
own adaptation and has created interest at CDC for
national use.
Most importantly, because of her vision and
leadership on this project, the activity has crystalized
the team of planners in PHP&R and has nurtured
relationships with the local health department staf.
This has increased morale, supported professional
growth and resulted in a sense of accomplishment by
everyone involved.
Pictured from L-R: Dr. Julie Casani, Shanae Godley, and Dr. Megan Davies
Dr. Jessica
Rinsky joins the
Communicable
Disease Branch
as the 35th Epi-demic
Intelli-gence
Service
(EIS) Officer.
Jessica Rinsky, PhD is
our newest EIS Officer
to be assigned from
CDC to the Medical Consultation Unit, Communica-ble
Disease Branch. Jessica recently completed her
PhD in Epidemiology from the University of North
Carolina Gilling's School of Global Public Health. Dur-ing
her two-year fellowship, she will monitor surveil-lance
data, conduct outbreak investigations, and
support local health departments by serving as an on
-call epidemiologist.
Davidson County Salmonellosis
Outbreak One of Largest in State
History.
During June 2015, a popular BBQ restaurant, Tarheel
Q, located in Lexington, NC was the source of
Salmonella typhimurium infections for more than
275 patrons. A joint investigation identified
improperly cooked pork product as the likely vehicle
for disease transmission. Pork product tested at the
State Laboratory of Public Health demonstrated an
identical Salmonella strain with testing performed
on human cases. After control measures were
implemented and two incubation periods passed,
the outbreak oficially ended on August 8, 2015.
The EpiNotes Newsletter | Page 12
EpiNotes Editor: Aaron Fleischauer, PhD MSPH
State of North Carolina │ North Carolina Department of Health and Human Services
North Carolina Division of Public Health │ Epidemiology Section
www.ncdhhs.gov
N.C. DHHS is an equal opportunity employer and provider. 7/13
Communicable Disease Branch
(Epi 24/7 on-call)
919-733-3419
HIV/STD Program
919-733-7301
TB Program
919-733-3419
Occupational & Environmental and Epidemiology Branch
919-707-5900
Public Health Preparedness and Response
919-715-0919
PHPR Emergency 24/7
919-820-0520
Rabies Emergency
(Nights, Weekends, Holidays)
919-733-3419
State Laboratory of Public Health
919-733-7834
Courtesy of NC.gov